Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Friday, November 04, 2011

Forced Productivity: Our New Sweatshop

We have to ask ourselves how are we going to take care of 32 million more patients in 2014 with a limited number of physicians to care for them. Better yet, how are we going to do this and save money doing it.

Thanks to our central regulators, they have already figured out how to do this: forced productivity. The term itself brings to mind images of outer Siberia or Chinese sweat shops. Lower costs and expect the workers to do more to make the same income. Perhaps you haven't heard this term in our President's health care reform speeches.

But it's out there as a lynchpin in the brave New World of medicine. I heard this term listening to a recent lecture by banker Steven Lipstein, the new Vice Chair of the Board of the Patient Centered Outcomes Research Institute (PCORI) established under the Patient Protection and Affordable Care Act during a recent lecture at our institution. He is also President and CEO of BJC HealthCare in St. Louis, MO who also serves as Chairman of the Board of Directors of the St. Louis Federal Reserve Bank.

But as I listened to Mr. Lipstein I wondered, how and when will forced productivity end?

How much forced productivity can doctors tolerate before they snap. How many hours can they endure when no workday or geographic restrictions are in place for them while residents and medical students saunter home after an eight-hour work day? How much forced productivity can they endure to repay their huge medical school loans?

Most importantly, what debts are incurred by "forced productivity gains" to patients? If patients think their doctors are busy now as they stuggle to get an appointment or feel rushed when the do get an appointment, just wait.

Mr. Lipstein understood the principles of the new health care climate well when he explained how we got to where we are today. What he doesn't understand at all, however, is the unintended consequences that are likely to occur as a result of these changes.

Basically Mr. Lipstein gave on overview of the various laws that have lead to where we are today, from ARRA, to PPACA. The tenets of his background reviewing "productivity" can be found in this McKinsey white paper.

Basically, he mentioned how the new health care laws have mainly affected the payers so far, but already has affected doctors by establishing requirements for EMR (ARRA) and cutting their (Medicare) payments to provide "forced productivity."

A better question might be why a banker and health care executive sits as vice chair of the committee responsible for comparative effectiveness research. Wouldn't be the money involved, would it?

I am from St. Louis. Perhaps this explains why one of my loved ones went to BJC with a common cardiac problem and was not only bulled into getting a (poorly installed) pacemaker that he did not need, but subjected to repeated, brutal verbal abuse by two other doctors in an attempt to coerce him into submitting to an implanted defibrillator that, as we later learned, was explicitly NOT recommended by clinical practice guidelines and could have interacted catastrophically with the months of iatrogenic AFib he ended up suffering. We assumed there must be some fanatical ideology involved in their behavior, since the staff doctors are on salary and therefore should not have had a profit motive for shoving people into excess $60K procedures. Of course if there is some corporate thug looming over them yammering for more of those procedures, I imagine that could crank up their hostility levels a little. If either of us ever consents again to an invasive procedure other than an explantation, it will be after we have read every relevant clinical trial, because "Just Trust the Doctor" doesn't work out well at all in modern America.

I found your blog searching for "doctor" and "sweatshop". How right you are. My med school loans are long paid off, but retirement is not yet in sight. My belief is that the writing is on the wall for all to see, if individuals only bother to open their eyes. I am working fervently on my exit strategy, so as not to end up as fodder for Mr. Lipstein's or "Dear Leader's" goal of turning physicians into hamstrung guideline following functionaries.

That being said, I have little sympathy for the current crop of future and young docs in the system. You mortgaged your future, in a metaphorical sense, on a house that you will never be allowed to live in. What were you thinking? It reveals a glaring deficiency of critical thinking skills to have even put yourself in that position. The reward for that touchy feely desire to "help people" will be a life of forced servitude in an to attempt to dig yourself out of a deep economic hole. I can guarantee you that the touchy feelies will be replaced with the hard-won knowledge that you have been had.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.